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Risk Stratification for Diabetic Foot Disease

Referral to the Specialist Foot Service

A Multidisciplinary Foot Clinic is held weekly in the Diabetes Centre at Ninewells Hospital. This has input from a Diabetologist, State Registered Podiatrists, Orthotists and the Vascular Surgery team Satellite foot clinics are available at Perth Royal Infirmary, Arbroath Infirmary and Forfar Whitehills Community Care Centre. Varicose ulcers should not be referred to the Foot Clinic and are generally better referred to the Dermatology department Patients with any of the following should be referred without delay to either the Specialist Podiatrist or to the appropriate Medical team:

• Non-healing ulcers of longer than 4 weeks duration
• Active Charcot's Arthropathy
• Deep spreading infection
• Suspected osteomyelitis
• Painful neuropathy that is difficult to control

Management of "Simple" Diabetic Foot Ulceration

The Tayside Diabetes Foot Service does not advocate the use of antibiotics for all patients with foot ulcers. They should be reserved for ulcers which show clinic signs of infection including redness, swelling and warmth.

1. Superficial swabs of ulcers are rarely helpful
2. When trying to culture an ulcer, deep tissue should be swabbed and if necessary, deep infected tissue should be sampled using needle and syringe.
3. Please refer to Tayside Wound Formulary on NHS Tayside Intranet under Directorates and Departments>Pharmacy> Tayside Medicines Unit> Tayside Area Prescribing Guide> Wound Management Formulary>section 6 on diabetes for advice on dressings.

If antibiotic therapy is indicated, the following are recommended:
Minor superficial infections: Co-amoxiclav 625mg tds OR Flucloxacillin 1000mgs qds and Metronidazole 400mg tds. Use initially for 2 weeks

Spreading and/or Deep infection: Clindamycin 300 mgs qds and Ciprofloxacin 750 mgs bd – usually for a minimum of 3 weeks. If there is suspicion of osteomyelitis, then treatment should be for a minimum of 6 weeks. Consider increasing the dose of Clindamycin to 450-600mg qds for large individuals.

MRSA Infections: Treatment for these should be discussed with the consultant at the Diabetes Foot Clinic or the consultant in Infectious Diseases.

Referral to Diabetes Specialist Foot Service

Consideration should be given to refer patients to a specialist foot clinic if there has been a foot ulcer present for 4 weeks which does not appear to be healing or showing signs of improvement. If there is any concern about severe or spreading sepsis, the patient can be referred at any time. The clinic is also a source of advice for difficult painful neuropathy.

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